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As lawmakers around Pennsylvania Avenue struggle to create a plan for meaningful health care reform, many people - including President Barack Obama - are finding inspiration in Pennsylvania for how to deliver better care for less money.

Geisinger Health System, which is based in Danville but stretches from East Stroudsburg to State College, practices many of the cost-saving principles touted by the Obama administration and is making people healthier in the process.

Geisinger has a unique model for delivering care: Many of its nearly 800 doctors, whether hospital specialists or primary care physicians, are salaried staff members, which removes some of the profit incentive of paying physicians piecemeal.

It has its own health insurance company - Geisinger Health Plan - that covers about 230,000 state residents and uses its copious data to help doctors coordinate patients' care.

And, it has a sophisticated and well-established electronic health records system that is fully implemented in its three hospitals and spread throughout its 43-county network of primary care clinics.

Its success has a lot to do with the integration of this system, which encourages doctors to work together and allows the company to allocate financial resources where they are needed.

"They're not playing just one note here, they're playing a symphony," said Dr. Donald Berwick, the chief executive of the Institute for Healthcare Improvement. Geisinger has improved its information, its clinical culture, its safety, its network. "Any organization would feel good to have accomplished any one of them," he said, "but the fact that they're doing it as a total system with all of these different things in play is unusual and it's a secret to their systemic success."

Daniel West, Ph.D., chairman of the health administration and human resources department at the University of Scranton, called Geisinger "one of the leading health care organizations in Northeast Pennsylvania," with an emphasis on "leading." They have shown themselves willing and able to pioneer new strategies in ways other local providers have not and they have the ambition to be viewed as a national player, he said.

Geisinger's drive to innovate, and the positive results of those innovations for both acute and chronic health care, have earned it mentions by the president, in a much-discussed June 2009 article in The New Yorker, and as a model by the Medicare Payment Advisory Commission (MedPAC), the financial oversight commission for Medicare.

Many of its innovations have been designed to counter what Dr. Alfred Casale, Geisinger's director of cardiothoracic surgery, calls the "quintessence of perversity" where doctors are typically reimbursed based on how much they do, not how well they do it. Hospitals make more money if patients have more complications, not fewer.

'Dirty little secret'

With a 3-year-old program called ProvenCare, Geisinger has found that good outcomes can coexist with less expensive care.

"We've known that as a dirty little secret for a really long time, but we've had precious few examples where you can actually demonstrate it," Dr. Casale said.

The pilot for the program began with elective heart surgery and came with a guarantee. Insurers pay a flat fee from the time the surgery is deemed necessary until 90 days after the operation, and if the patient develops a complication within that time, Geisinger will not send out another bill.

The reason the company is willing to make that bet is because it has developed a process for helping ensure that preventable problems are less likely to occur. Geisinger's eight cardiac surgeons took best practices designed by the American Heart Association and the American College of Cardiology and translated them into 40 specific steps that should happen for every procedure.

Geisinger then built the process into the electronic health system so that every step must be completed every time, unless a surgeon notes a reason for not taking it.

When the program began, Geisinger surgeons were following best practices about 59 percent of the time - slightly better than the 55 percent of basic recommended care given to an average patient in America, according to a 2003 study by the RAND Corp. Within three months, patients were receiving 86 percent of the steps. Now, the number is consistently 100 percent.

Dr. Deepak Singh, a cardiac surgeon based out of the Richard and Marion Pearsall Heart Hospital at Geisinger Wyoming Valley, said ProvenCare has made him more confident that every patient gets a thorough treatment every time.

"What we want is good results by purpose, not by luck," he said.

So far, the heart surgery program has produced good results for Geisinger and its health plan, as well as for its patients. Complications were reduced by more than 20 percent and readmissions within 30 days fell by 44 percent. The average hospital stay was reduced by half a day. At the same time, the hospitals saved money by streamlining procedures and the flat-fee gamble paid off for the health plan.

"That's part of the reason the federal government is interested," Dr. Casale said. "You got patients doing better, the hospitals have made more money, the health plan spent less money and the providers - the nurses, the docs, the physicians assistants - have this pride and reward of knowing we're more effective. What we're doing is working better."

Model practice

ProvenCare has since become a generalized model for how Geisinger uses best practices to standardize care. It has expanded to other treatments, including total hip replacement, bariatric surgery and perinatal care. And each new application was selected to test some boundary of the ProvenCare method to see if it can have the same positive effects on more and more kinds of treatments, Dr. Casale said.

The idea that applying best practices to treatment all the time is not limited to the inside of the Geisinger hospitals' walls. In its outpatient clinics and primary care sites, doctors have committed to meeting agreed-upon quality standards for chronic diseases, so that patients with diabetes, kidney disease and heart failure are more likely to get all of the recommended care that can help keep them out of the hospital.

In clinics that participate in Geisinger's medical home initiative, teams coordinate a patient's treatment and help them transition in and out of hospitals or nursing homes. The health-plan-provided nurse coordinator works side by side with a primary provider and is on-call for high-risk patients 24 hours a day. Doctors call patients within a week of a procedure to make sure they are keeping up with their medicines. And the practitioner's reimbursement is tied to how good the patient's outcomes are.

Janet Tomcavage, vice president of health services for Geisinger's health plan, said the program works because the health plan partners with physicians, whether they are Geisinger doctors or not.

"The health plan knows lots of things about the patient, and the provider manages the care," she said. "If they don't have access to all the data and all of the information, then they don't know necessarily if a patient's seeing a specialist or which specialist or the last time they saw them.

"Marrying those two levels of information and skill sets together is what we think has helped us provide less fragmented, better coordinated care for patients."

Ms. Tomcavage said physicians in the medical home program have seen about a 15 percent reduction in heart failure patient readmissions, and there have been measurable improvements in hospital readmissions for chronic diseases across the board.

The successes are particularly remarkable in the context of national trends. About one of every five Medicare patients across the country goes back to the hospital within 30 days, at a cost of about $15 billion according to MedPAC. The commission estimates $12 billion of that is spent on potentially preventable readmissions.

Geisinger growth

At the same time that Geisinger has been making clinical improvements, it has also been making physical improvements to its facilities. And it is growing.

Geisinger will not confirm what would be the most noteworthy growth in Scranton: a potential Geisinger partnership with Community Medical Center, which Blue Cross of Northeastern Pennsylvania President and CEO Denise S. Cesare has said the two providers are considering.

"We are always talking with other providers about ways we can improve care for the community," Geisinger spokeswoman Amy Lingobardo said when asked if Geisinger is in talks with CMC.

Geisinger recently issued $230 million in bonds to pay for expansion and improvements and to refinance outstanding debt. In a positive bond rating report by Standard & Poor's, Geisinger was credited with "an impressive business position," strong revenue growth and management, and successful adaptation to a slower growth environment.

In Wilkes-Barre, where Geisinger has two hospital campuses, the health care provider is putting the final touches on several new or expanded facilities, including an updated emergency room and an expanded Henry Cancer Center.

During a tour of the new Critical Care Building at Geisinger Wyoming Valley, which opened as a trauma center last year, Dr. Steven Pierdon, the chief medical officer of Geisinger Northeast, pointed out medical instruments suspended from the ceiling for cleanliness and ease of use. Near patients' rooms, nurses leaned over computer terminals that allow them to track a patient's medical history even while looking through large windows at the patient in the bed.

If a patient is transferred from one room to another, flat screen televisions throughout the corridors highlight the change.

Community-oriented care

One of the things that sets Geisinger apart even among integrated health care systems around the country is particularly good for the communities where it functions, according to Dr. Robert Berenson, a health care expert and fellow at the Urban Institute. The nation's best integrated systems are still challenged by the difficulty of merging the ideals of personalized, community-based medicine with the sophistication of large organizations.

"I think Geisinger, as much as any organization in the country, is able to somehow merge the decentralized, patient-friendly notion of the community doc with the organizational advantages of an organization," he said.

They are also concerned with the negative impact their success might have on community hospitals in the regions where Geisinger has spread its practice sites, he said.

As Geisinger succeeds at reducing hospitalizations - through ProvenCare or medical home or any of its other innovations - it is putting a financial strain on nearby hospitals.

"It's obviously better for patents and it's better for the nation's health care system," Dr. Berenson said, "but the business model for hospitals is to keep beds full."

Justin Matus, Ph.D., a professor at the Sidhu School of Business at Wilkes University, said Geisinger deserves all of the praise it has been receiving but he does not advocate that it should be the only health care provider around, nor does he believe it has "extraordinary competitive advantages over other local health care systems."

"As a more generalized statement, health care in this area is very good," he said. And improvement at one site only compels the others to improve.

"When one organization gets better, everybody else catches up," he said, "whether they like it or not."

Contact the writer: llegere@timesshamrock.com

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7 posted comments

As a specialist providing health care in eastern Pennsylvania, I was surprised to find out the Geisinger health plan is under a Pennsylvania state agency that allows no medical model. I saw a child prescribed a medication not in their formulary. I requested an appeal and asked for a peer review. The case manager assured me that I was going to discuss the case with a peer. Being board certified in my specialty, I was surprised when their reviewer called me and informed me that not only was she not a member of my specialty but that she also did not attend medical school. Could this be oneof many factors contributing to their lower costs? Is this a feature one would appreciate having in their insurance plan?

Not suprised to see a doctor unhappy with his experience, "I make 4 times as what I used to"...gee and you wonder why costs are out of control. Most patients, however, find the Geisinger experience to extraordinary, and isn't that what's important here...I have never had an issue in my 13 years on the health plan with seeing a doctor, a specialist, getting a test, seeing the results, having no paperwork, and having my costs stable from my employer. Nothing is perfect, but their integration system allows for faster results at a cost savings. I don't know if the govt model will be as efficient or even look anything like what I experienced with Geisinger but if it tries to, then so much the better.

Could not disagree with you more Jeff! I recently switched from a 28years private practice physican with records of visits, testing, and hospitalizations scattered all over the place to a Geisinger Primary care facility. Couldn't be more pleased!! Little or no waiting to see my primary care physican, prompt online display and explanation of lab and diagnostic testing, minimual waiting for X-rays, scans etc., and pleasant and efficient staff both in the office and at the hospital!! Never seen anything quite like it and I love!!

Thats it...let the doctors do all the work and let the beaucrats and insurance companies keep all the profits. I was a geisinger doc on a salary then I left and went out on my own.Now I make 4 times as much money while doing the same amount of work.